Biomedical subjects
Publications and source records attributed to D Rosenthal.
The studies test the role of examples in the learning of diagnostic rules in dermatology. The specific examples used are shown to have a substantial biasing effect on diagnostic accuracy.
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To our knowledge, a particularly lethal complication of carotid endarterectomy, intracerebral hemorrhage, has not been given due consideration in the literature concerning carotid surgery. In the Atlanta area, massive intracranial hemorrhage developed in ten patients following routine carotid endarterectomies performed during a recent ten-year period. All ten of the patients in this series died despite a variety of therapeutic interventions. Risk factors may include the following: extreme arterial stenosis with resultant postoperative hyperperfusion, involvement of multiple extracranial cerebral vessels, postoperative systemic hypertension, and administration of anticoagulant or antiplatelet medications. Unfortunately, identification of the subset of patients potentially at risk for this complication is difficult, and, to date, therapy has been generally ineffective.
The ideal management of the patient with an asymptomatic stenosis of the extracranial internal carotid artery remains controversial. The purpose of this article was to evaluate the effects of prophylactic carotid endarterectomy (CE) done to treat asymptomatic carotid stenosis (greater than 50% diameter reduction by angiography) 10 years later. In 1976, 42 prophylactic CEs were performed. There were no postoperative deaths or strokes. During 10-year follow-up two strokes occurred in the operated hemisphere; one stroke was fatal and was due to an intracranial hemorrhage, whereas the other stroke was thromboembolic in origin. Two other patients suffered strokes in the contralateral hemisphere and seven patients had transient ischemic attacks in the contralateral hemisphere, which necessitated CE. The survival rate at the end of the study period by life-table analysis was 57% (mean 8.7 years). Sixteen late deaths occurred, with coronary artery-related disease the most common cause of death. This review with actual 10-year follow-up demonstrated that prophylactic CE may be performed with minimal risk, that late stroke in the operated hemisphere was negligible, and that long-term survival was similar to that of a comparable age-matched population, possibly because late deaths attributed to stroke were reduced. On the basis of long-term follow-up, CE to treat asymptomatic high-grade carotid stenoses appears to be indicated in appropriate patients.
The chronic leukemias are associated with significant morbidity from splenic enlargement and hyperfunction. Although some patients with chronic leukemia benefit from splenectomy, the indications for operation are unclear. To identify those patients who benefit most from splenectomy, nine patients with chronic lymphocytic leukemia (CLL) and eight patients with chronic granulocytic leukemia (CGL) who had splenectomy to palliate the symptoms of massive splenic bulk or to improve the hematologic sequelae of splenic hyperfunction were studied. Splenectomy for bulk symptoms provided good palliation of symptoms, but the duration of the benefit was limited by the stage of the disease. Five of eight patients with CGL with bulk symptoms died within 6 months of operation. Splenectomy for hyperfunction was limited to a short-term hematologic response. In three of four patients with CLL who were Coombs positive, the presence of autoantibodies correlated with a recurrent transfusion requirement within 3 months of splenectomy. Thus, the benefit of splenectomy for bulk symptoms must be weighed against the risk of surgery and the patient's limited life expectancy. The benefit of splenectomy for treatment of splenic hyperfunction depends on the stimulus to hyperfunction and may not be beneficial for patients with refractory autoimmune anemias.
To evaluate the benefits and disadvantages of autologous intraoperative transfusion during major aortic reconstructive procedures, we retrospectively studied 50 patients who had major aortic revascularization procedures without the use of autologous transfusion devices (group 1) and prospectively evaluated a second 50-patient cohort having similar procedures, but with the use of the autologous transfusion device for salvaging and reinfusing lost blood. Both groups were assessed for preoperative risk factors and postoperative complications. We found a somewhat lower morbidity in the autotransfusion group and more complete replacement of blood loss. Autologous transfusion accounted for approximately 75% of all transfused blood in group 2, tremendously reducing blood bank requirements. In addition to reduction of immediate postoperative morbidity, further risks associated with homologous transfusion such as hemolysis, posttransfusion hepatitis, transfusion-related acute lung injury, anaphylaxis, and transfusion-transmitted acquired immunodeficiency syndrome (AIDS) were markedly reduced or eliminated.
Recent research suggests that children's understanding of the interior of the body and its functioning develops in an orderly sequence that parallels cognitive development generally. Two hundred and ten healthy school children aged 5-11 years were studied individually and required to draw the interior of the body inside a body outline provided. In order to overcome the constraints of pictorial representation, they were also interviewed about their understanding of the contents of the body. Changes were measured in the number and nature of body parts drawn and described. Responses on drawings were coded to differentiate level of integration of organs and parts into body systems. The findings demonstrate a significant increase in conceptual sophistication with age. Developmental changes in conceptualization of the body are interpreted within the context of a Piagetian model of cognitive development, supporting the possibility of delineating stages in the development of the child's thinking about the body interior. The implications of the findings for communicating with children about health and illness are discussed.
Nineteen patients with Hodgkin's disease who relapsed primarily in nodal sites after intensive combination chemotherapy were retreated with wide-field radiation therapy alone or with additional chemotherapy between January 1971 and December 1984. Six patients presented in second relapse and 13 patients in first relapse. Seven patients were treated with combination chemotherapy and radiation therapy and twelve patients were treated with radiation therapy alone. Radiation therapy field sizes and doses were similar to those recommended for early-stage Hodgkin's disease patients treated with radiation therapy alone. The 5-year actuarial freedom from relapse (FFR) and survival following retreatment were 48% and 69%, respectively. Twelve patients are currently disease-free 12 to 172 months following retreatment. Wide-field radiation therapy alone or with additional chemotherapy should be considered for patients with advanced Hodgkin's disease who relapse in nodal sites after initial combination chemotherapy.
The objective of the present study was to contribute to the development of a noninvasive method for the evaluation of portal circulation using rectally administered radiotracers in dogs. 99mTc absorption was previously checked in rabbits and the present study reports similar results in dogs. Circulation time between the terminal large bowel and the liver (RL-t) and heart (RH-t) was determined by external counting at the hepatic and cardiac level with a large-field computerized gamma camera. In 16 animals studied, average RL-t was 5.2 s and RH-t 8.6 s. In 3 animals with partial binding of the portal vein, RL-t increased to 32, 44 and 34 s. Being noninvasive and harmless, this method could be used to study portal circulation in several physiopathological conditions of the human liver.
Kinetic studies of T4 and T3 metabolism were performed on 5 healthy volunteers from Rio de Janeiro to obtain normal values for thyroid hormone metabolism. 125I-T4 and 131I-T3 were administered in bolus and blood samples taken during 7 days. Circulating tracers were isolated by Sephadex G-25 chromatography. The kinetic parameters of T4 and T3 metabolism were calculated by noncompartmental methods. Metabolic clearance rates were 1.04 l/day for T4 and 20.7 l/day for T3. The daily production rate was estimated at 94 micrograms/day for T4 and 23 micrograms/day for T3 and their exchangeable pools at 914 micrograms and 25.5 micrograms, respectively. These values are well within the range of those reported by North American or European authors for normal subjects.
Penetrating arterial injuries can result in the formation of a traumatic false aneurysm or an arteriovenous fistula. Traumatic arteriovenous fistulas of the mesenteric circulation are extremely rare, with only 15 operated cases reported in the English language literature that involved the superior mesenteric artery and vein. Although surgical intervention has been considered the most successful method to treat traumatic mesenteric arteriovenous fistulas, percutaneous transcatheter embolization has been occasionally advocated in the management of small iatrogenic fistulas. We report a case of a gunshot wound patient who had an 8 cm abdominal aortic false aneurysm, as well as a high-flow arteriovenous communication between the superior mesenteric artery and vein, which were successfully treated by a combination of aorto-superior mesenteric bypass and postoperative percutaneous transcatheter embolization. A review of the literature is also included.
Serum thyroxine and triiodothyronine, radioiodide thyroid uptake and thyroid peroxidase (TPO) activity were studied over a 2 to 5 day period in fasting rats treated (F+) or not (F-) with TSH. In F- rats, TPO activity was transiently decreased on the 3rd day, whereas in F+ it was always higher than in controls. On the 5th day, the 2 h thyroid uptake of 131I decreased in F-, while the 24 h uptake increased in both F- and F+. Serum T3 and T4 decreased in both fasting groups. Thus, not all effects of fasting on rat thyroid function are reverted by TSH administration, suggesting intrinsic impairment of glandular function.
Thyroglobulins (Tg) 27S and 19S and their hormonal content were determined in normal (N = 6), paranodular (N = 4) and hypofunctioning nodular (N = 8) human thyroid tissues. The proportion of Tg 27S and the hormonal content of Tg 19S were significantly decreased in cold nodules. In normal tissues, the molar ratio of T4 in Tg 27S (2.8) was almost twice that found in Tg 19S (1.7), while for T3 the molar ratio in Tg 27S (0.06) was lower than in Tg 19S (0.09). These results indicate that Tg 27S is predominantly formed from well iodinated T4-containing Tg 19S molecules.
Aspirin (ASA) and dipyridamole (DIP) have been shown to reduce the incidence of transient ischemic attacks (TIAs), but aspirin's ability to reduce the incidence of postoperative neurologic deficits in patients who require carotid endarterectomy (CE) is controversial. To evaluate the role of adjunctive ASA/DIP in conjunction with CE, 908 CE cases were reviewed. Four hundred sixty-seven patients took ASA (650 mg/day) and DIP (150 mg/day) preoperatively, while 381 received no ASA/DIP. There was no statistical difference in the distribution of postoperative neurologic deficits. Twenty-six transient deficits occurred: 14 (53%) patients were taking ASA/DIP, whereas 12 (47%) were not. Seventeen permanent deficits occurred: ten (58%) patients were taking ASA/DIP and seven (42%) were not. ASA/DIP are useful medications in combating ischemic cerebrovascular disease, but ASA/DIP cannot replace precise operative technique which affords unequaled protection against a postendarterectomy neurologic deficit.
This study was done to evaluate the effect of aspirin (ASA), dipyridamole (DIP), and warfarin on 406 patients who had femoropopliteal-tibial operations with saphenous vein (SV), umbilical vein (UV), polytetrafluoroethylene (PTFE) and Dacron (DuPont, Wilmington, DE). Above-knee bypasses were performed in 181 patients: 77 were taking ASA and DIP at the time of operation, 41 were placed on postoperative "low-dose" warfarin, whereas 63 did not receive adjunctive medications. Late patency demonstrated no significant difference among the groups based on graft material used (SV 71%, UV 68%, PTFE 66%, and Dacron 65%) (P less than .25). Below-knee femoro-popliteal bypasses were performed in 183 patients: 82 were taking ASA and DIP at the time of operation, 40 were placed on warfarin postoperatively and no medications were given to 41 patients. Late patency rates (39 months) demonstrated that SV (62%) was superior to UV (51%), PTFE (30%), and Dacron (18%) (P less than .01). Femorotibial-peroneal bypasses were done in 42 patients: 13 patients were taking ASA and DIP at operation, 21 were placed on warfarin postoperatively and 8 received no medication. SV late patency (33 months) was again superior (43%) to UV (31%); no PTFE or Dacron grafts functioned after 24 months. Patients who took warfarin and ASA had the best early (16 months) patency results. Above-knee prosthetic grafts achieved late patency rates similar to SV while reducing operative time, shortening recuperation, and sparing the saphenous vein for use in the coronary or infrapopliteal vessels. In below-knee bypasses SV was superior to prosthetic grafts, with or without the use of ASA and DIP or warfarin.(ABSTRACT TRUNCATED AT 250 WORDS)
Lower extremity pain caused by exercise but relieved by rest is usually a reliable symptom of chronic arterial insufficiency. However, similar discomfort often occurs in patients who have neurospinal compression. Furthermore, both arterial occlusive disease and neurogenic causes of lower extremity discomfort may present simultaneously. Forty patients with symptoms that suggested intermittent claudication comprised our study group. All had non-arterial cause of their complaint. The nonvascular origin of the symptoms was suggested initially by clinical evaluation in 30 patients and by noninvasive evaluation in 25 patients. The neurospinal origin of symptoms was obscured in 15 patients because of the concomitant presence of significant arterial occlusive disease as demonstrated by noninvasive arterial testing. Twelve of these 15 patients underwent arterial reconstruction, which did not relieve their symptoms. Subsequently, the neurospinal origin of their symptoms was proven by appropriate evaluation and therapy. Forms of evaluation that proved helpful in the differential diagnosis were lumbosacral spine x-rays, electromyography, nerve conduction velocity studies, computerized tomography, Doppler noninvasive assessment and, at times arteriography and contrast myelography.
To investigate the contribution of genetic and environmental factors in the etiology of mood disorders, a study was initiated to examine the frequency of psychiatric disorders in the biological and adoptive relatives of adult adoptees with mood disorders and in matched normal adoptees. Psychiatric evaluations of the relatives were made on the basis of independent blind diagnoses based on mental hospital and other official records. Analysis of the data showed an eightfold increase in unipolar depression among the biological relatives of the index cases and a 15-fold increase in suicide among the biological relatives of the index cases. These data demonstrate a significant genetic contribution to unipolar depression and suicide. They fail to disclose a significant contribution of family-associated transmission in the genesis of the mood disorders.
Neutropenic enterocolitis, also known as typhlitis or ileocecal syndrome, is a recognized complication of the treatment of hematologic malignancies and usually is fatal. The pathologic findings consist of bowel-wall ulcerations and necrosis with bacterial or fungal invasion. These findings are usually limited to the ileum, cecum, ascending colon, and appendix. The syndrome occurs in a select patient population who generally have 1) a hematologic malignancy, 2) neutropenia, 3) thrombocytopenia, 4) a recent course of chemotherapy, and 5) a recent course of antibiotics. This syndrome also can arise spontaneously in patients with aplastic anemia or cyclic neutropenia. The clinical presentation consists of a high fever and right-sided abdominal pain with evidence of peritoneal irritation. Recommended therapy is right hemicolectomy.